Membership of the Royal College of General Practitioners (MRCGP) Applied Knowledge Test (AKT): Evidence, Administration and Health Informatics Syllabus

What is heterogeneity in a meta-analysis and how is it quantified?

Heterogeneity is variability in results across included studies beyond chance. It is assessed with the $I^{2}$ statistic ($> 50\%$ suggests substantial heterogeneity) and the chi-squared (Cochran's Q) test.

Distinguish fixed-effect from random-effects meta-analysis models.

A fixed-effect model assumes one true underlying effect and that differences are due to chance only. A random-effects model assumes effects vary between studies and gives wider confidence intervals; it is preferred when significant heterogeneity exists.

What is a funnel plot used to detect?

A funnel plot detects publication bias. Each study's effect size is plotted against its precision (e.g. standard error). Symmetry suggests no bias; asymmetry (missing small negative studies) suggests publication bias.

On a forest plot, what do the vertical 'line of no effect', the diamond, and the box sizes represent?

The vertical line of no effect sits at $1$ for ratios or $0$ for differences. The diamond is the pooled summary estimate with its CI. Each square is a study's point estimate, its size proportional to that study's weight; the horizontal line is its CI.

On a forest plot, how do you tell if an individual study and the pooled result are statistically significant?

An individual study is significant if its horizontal CI line does not cross the line of no effect. The pooled result is significant if the diamond does not touch or cross the line of no effect.

List the key Wilson and Jungner criteria for a screening programme.

The condition should be an important health problem with a recognisable latent/early stage and understood natural history. There should be a suitable, acceptable test, an accepted effective treatment, agreed policy on whom to treat, available facilities, and the cost should be balanced against benefit; screening should be a continuous process.

Define lead-time bias and length-time bias in screening.

Lead-time bias: screening appears to prolong survival merely by diagnosing disease earlier, without delaying death. Length-time bias: screening preferentially detects slow-growing, less aggressive disease, falsely improving apparent outcomes.

Define incidence and prevalence, and state how they relate.

Incidence is the number of new cases in a population over a time period; prevalence is the total number of existing cases at a point or period. Approximately, $$\text{prevalence} \approx \text{incidence} \times \text{duration}$$ for stable chronic conditions.

Differentiate standardised mortality ratio (SMR) and its interpretation.

$$SMR = \frac{\text{observed deaths}}{\text{expected deaths}} \times 100$$ An SMR of $100$ equals the reference population; $> 100$ indicates excess mortality, $< 100$ indicates lower mortality than expected.

Distinguish QALY and DALY as measures of disease burden.

A QALY (quality-adjusted life year) measures health gain combining quantity and quality of life, used in cost-utility analysis (NICE uses a threshold around \pounds20{,}000-30{,}000 per QALY). A DALY (disability-adjusted life year) measures disease burden as years of life lost plus years lived with disability.

In UK primary care, what coding system is used and what replaced Read codes?

SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms) is the mandated clinical coding standard in NHS primary care, having replaced Read codes (which were retired in 2018-2020).

Describe the stages of the clinical audit cycle.

1) Identify a problem and set standards/criteria; 2) collect data on current practice; 3) compare performance against the standard; 4) implement change; 5) re-audit (collect data again) to 'close the loop' and confirm improvement.

How does clinical audit differ from research?

Audit measures practice against an existing accepted standard to improve local care and does not test new interventions or generate new knowledge; it usually needs no ethics approval. Research tests a hypothesis to create generalisable new knowledge and requires ethical approval.

What is the Plan-Do-Study-Act (PDSA) cycle in quality improvement?

PDSA is an iterative method for testing change on a small scale: Plan a change, Do (implement on a small test), Study the results/data, Act (adopt, adapt, or abandon), then repeat. Multiple ramped cycles build toward sustained improvement.

What is a driver diagram in quality improvement?

A driver diagram is a structured tool linking an overall aim to primary drivers (high-level factors needed to achieve the aim) and secondary drivers (specific areas/interventions), helping identify and prioritise change ideas.

State the lawful bases for processing personal data under UK GDPR relevant to healthcare.

Processing requires a lawful basis (e.g. consent, contract, legal obligation, vital interests, public task, legitimate interests). Health data is special-category data needing an additional Article 9 condition, commonly provision of health/social care or public health.

What are the key data protection principles and individual rights under UK GDPR?

Principles: lawfulness/fairness/transparency, purpose limitation, data minimisation, accuracy, storage limitation, integrity/confidentiality (security), and accountability. Rights include access (subject access request), rectification, erasure, restriction, portability, and objection.

Summarise the Caldicott principles governing use of patient-identifiable information.

They require a justified purpose for using confidential data, using it only when necessary, the minimum necessary, on a strict need-to-know basis, with everyone aware of their responsibilities, compliance with the law, and recognition that the duty to share can be as important as the duty to protect.

When can a Med3 (fit note) be issued, and what are its two options?

A Med3 can be issued after the first 7 days of illness (patients self-certify the first 7 days, e.g. via SC2). It states the patient is either 'not fit for work' or 'may be fit for work' with suggested adjustments (phased return, amended duties, altered hours, workplace adaptations).

Who can now issue fit notes, and for how long can one be issued?

Since 2022, fit notes can be issued by doctors, nurses, occupational therapists, pharmacists, and physiotherapists. In the first 6 months of an illness a fit note can cover a maximum of 3 months; after 6 months it may be for a longer/indefinite period.

Who can complete the Medical Certificate of Cause of Death (MCCD), and what change came with medical examiners?

Since 2024, any registered doctor who attended the deceased in life can complete the MCCD (the previous '14-day attendance' rule was removed). All deaths in England and Wales not referred to the coroner must now be reviewed by an independent medical examiner before registration.

When must a death be referred to the coroner?

Refer when the cause is unknown, the death was violent/unnatural/suspicious, due to an accident, suicide, neglect, industrial disease, in custody/state detention, during or shortly after a procedure, or no doctor can certify the cause.

Outline the DVLA group 1 driving rules after a single unprovoked epileptic seizure and after a TIA/stroke.

First unprovoked/single seizure: must stop driving and not drive for 6 months (group 1). Single TIA or stroke: must not drive for 1 month, may resume if clinically recovered (no need to inform DVLA unless deficits persist or multiple TIAs).

State the DVLA group 1 rules after an MI/ACS and for relevant diabetes on insulin.

After MI/ACS treated successfully (with PCI), stop driving for 1 week; if no intervention, 4 weeks; DVLA need not be notified for group 1. Insulin-treated drivers must notify DVLA, have awareness of hypoglycaemia, no more than one severe hypo while awake in 12 months, and monitor glucose appropriately.

Whose legal duty is it to notify the DVLA of a relevant medical condition, and what should a GP do if a patient continues to drive against advice?

It is the patient's (driver's) legal duty to inform the DVLA. If a patient continues driving despite being unfit and refuses to stop, the GP should make every effort to persuade them, then may breach confidentiality and inform the DVLA medical adviser in the public interest, informing the patient first.

What is the Work Capability Assessment, and which benefit replaced Disability Living Allowance for working-age adults?

The Work Capability Assessment determines eligibility for Employment and Support Allowance / Universal Credit limited-capability elements, assessing functional ability via descriptors and points. Personal Independence Payment (PIP) replaced Disability Living Allowance for working-age adults, with daily living and mobility components.

State the five principles of the Mental Capacity Act 2005.

1) Presumption of capacity; 2) support people to make their own decision; 3) unwise decisions do not equal lack of capacity; 4) decisions for those lacking capacity must be in their best interests; 5) choose the least restrictive option. Capacity is decision- and time-specific.

List notifiable diseases a UK doctor must report and to whom.

Suspected notifiable diseases (e.g. measles, mumps, rubella, meningococcal disease, TB, food poisoning, cholera, diphtheria, acute hepatitis, whooping cough) must be reported to the local authority 'proper officer' / UKHSA, urgently and without waiting for laboratory confirmation.

How do clearance and half-life change drug dosing in renal and hepatic impairment?

Reduced renal clearance prolongs the elimination half-life of renally excreted drugs (e.g. gentamicin, digoxin, metformin), requiring dose reduction or interval extension. Hepatic impairment reduces metabolism of liver-cleared drugs and lowers first-pass clearance, also requiring dose reduction. Loading dose depends on volume of distribution, not clearance.

What is therapeutic drug monitoring and name key drugs requiring it?

Therapeutic drug monitoring measures plasma drug levels to keep concentrations within a narrow therapeutic range and avoid toxicity. Examples: digoxin, lithium, theophylline/aminophylline, phenytoin, gentamicin/vancomycin, and ciclosporin. Lithium is typically measured 12 hours post-dose.

Distinguish pharmacokinetic from pharmacodynamic drug interactions, with the main CYP enzyme effects.

Pharmacokinetic interactions alter absorption, distribution, metabolism, or excretion (e.g. CYP450 enzyme inducers such as rifampicin/carbamazepine reduce drug levels; inhibitors such as macrolides, azoles, and grapefruit juice raise levels). Pharmacodynamic interactions alter drug effect at the site of action (e.g. additive serotonergic or bleeding risk).

Classify adverse drug reactions using the Type A/Type B (and extended) system.

Type A (Augmented): dose-related, predictable from pharmacology, common, low mortality (e.g. bleeding on warfarin). Type B (Bizarre): idiosyncratic, not dose-related, unpredictable, higher mortality (e.g. anaphylaxis). Extended types: C chronic, D delayed, E end-of-treatment/withdrawal, F failure of therapy.

What are the legal requirements for a Schedule 2 controlled drug prescription?

It must include (handwriting no longer required but) the drug name, form, strength, total quantity in both words and figures, dose, patient's name and address, prescriber's signature and date. CD prescriptions are valid for 28 days, and a maximum 30-day supply is recommended.

State key principles of safe opioid prescribing for chronic non-cancer pain.

Use the lowest effective dose; risk of harm rises substantially above $120\,\text{mg}$ oral morphine equivalent per day with little extra benefit; review regularly; avoid combining with benzodiazepines/gabapentinoids; agree goals and an exit strategy; and recognise opioids are often ineffective for chronic pain.

What is polypharmacy, and what is deprescribing?

Polypharmacy is the concurrent use of multiple medicines (often defined as $\geq 5$); 'problematic' polypharmacy is when harm outweighs benefit. Deprescribing is the planned, supervised process of dose reduction or stopping of medicines that may be causing harm or no longer benefiting the patient.

Name validated tools used to review and rationalise medicines in older adults.

STOPP/START criteria (Screening Tool of Older People's Prescriptions / Screening Tool to Alert to Right Treatment) and the Beers criteria identify potentially inappropriate medications and prescribing omissions in older adults; a structured medication review applies them.

What is the Yellow Card Scheme and what should be reported?

The Yellow Card Scheme is the MHRA's system for reporting suspected adverse drug reactions, defective/falsified medicines, and device or vaccine problems. Report all suspected ADRs for newer drugs marked with a black triangle ($\blacktriangledown$), and all serious reactions for established drugs, even if causation is uncertain.

How is NHS general practice contracted and commissioned in England?

GP practices hold one of three contracts: GMS (General Medical Services, nationally negotiated), PMS (Personal Medical Services, locally agreed), or APMS (Alternative Provider Medical Services). Since 2022, Integrated Care Systems/Boards commission services, with practices grouped into Primary Care Networks; the Quality and Outcomes Framework (QOF) provides incentive payments.